Referral and Transition/Transfer of Care

Return to Patient Care
Return to FHIR Patient Care Resources

Introduction

Clinical medicine and health care have evolved from a simple patient-physician-nurse care delivery model to a multi-disciplinary, collaborative care delivery model. Patient's in today's complex care environment are often referred to the care of other specialized or super-super-specialized health care providers or provider organizations; or their care may required to be transitioned from one care setting/facility to another.

For complex care delivery models involving multi-disciplinary and multi-facilities to be effective, it is necessary that activities of the variety of health care providers and provider organisations are effectively coordinated.

The Referral processes and transition of care processes together with supporting administrative/financial and clinical data have been developed internationally to support the effective implementation of complex coordinated care delivery models.

Referral and Transition/Transfer of Care Project Scope Statement and Resources Proposal

• Project Scope Statement:

Referral FHIR Resoruces PSS - Approved 2014-04-29

• Link to Referral FHIR Resource Proposal (on FHIR wiki):

Referral FHIR Resource Proposal

Definitions

Referral

Referral is the process, with the intention of initiating care transfer, from the provider making the referral to the receiver.

NOTE: The essential components of referral are the intent and facilitation of transferring patient care in whole or in part from one health care provider or organization to another provider or organization. Self referral is also possible: a person, the subject of care, may be the referrer or the referee. Referral is normally accompanied by clinical information to responsibly enable takeover of such care by the referee.

Referral can take several forms most notably:

(a) Request for management of a problem or provision of a service e.g. a request for an investigation, intervention, or treatment.

(b) Notification of a problem with hope, expectation, or imposition of its management e.g. a Discharge Summary in a setting which imposes care responsibility on the recipient.

The common factors in all of these are a communication whose intent is the transfer of care.

(Source: Standards Australia AS4700.6 - HL7 v2.x Referral Messaging Specification. NOTE - the first sentence of this definition is slightly modified: the original statement - "Referral is the communication ..." is modified to - "Referral is the process...")

Transition of Care

• The term "care transitions" refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

For example, in the course of an acute exacerbation of an illness, a patient might receive care from a PCP or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition

(Source: http://www.caretransitions.org/definitions.asp)

• A position statement from the American Geriatrics Society defines transitional care as follows:

For the purpose of this position statement, transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient's goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.

(Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556-557)

• Meaningful Use Stage 2 Measures - (Eligible Hospital and Critical Access Hospital Meaningful Use Core Measures Measure 12 of 16) defines "Transition of Care" as:

"The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another"

(Source: Eligible Hospital and Critical Access Hospital Meaningful Use Core Measures Measure 12 of 16 - 2013-Nov, p.1)

• The Joint Commission has defined a “transition of care” as the movement of a patient from one health care provider or setting to another

(Source: The Joint Commission: Transition of Care Document - 2013, p.2)

• Key concepts that can be discerned from these definitions of "Transition of Care" are:

- coordination actions/processes

- transfer/transition of patient that occurs between

~ different levels of care within the same location (e.g. from ICU to general medical unit)

~ different locations/care settings (e.g. from acute care setting/facility to long term care or skilled nursing facility); or

• NOTE:

- "Transition of Care" is different from another concept "Transition Care" (in Australia)

- "Transition Care" in Australia is a program funded by the Australian Federal Department of Health

o Transition Care provides short-term care that seeks to optimise the functioning and independence of older people after a hospital stay.

o Transition Care is goal-oriented, time-limited and therapy-focussed.

o It provides older people with a package of services that includes low intensity therapy such as physiotherapy and occupational therapy, as well as social work, nursing support or personal care

o It seeks to enable older people to return home after a hospital stay rather than enter residential care prematurely.

o The Program facilitates a continuum of care for older people who have completed their hospital episode, including acute and subacute care2 (e.g. rehabilitation, geriatric evaluation and management), and who need more time and support to make a decision on their long term aged care options.

(Source: Australian Government Department of Health and Ageing: Transition Care Program Guidelines 2011)

Transfer of Care

Transfer of care is the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate

(Source: http://www.med.wisc.edu/files/smph/docs/compliance/compliance-transfer-of-care-definition-2011.pdf)

• Key concepts that can be discerned from this definition of "Transfer of Care" are:

- actions/processes

- relinquish of care responsibility by one provider to another

- explicit agreement of accepting clinician to take over this responsibility

- the relinquished responsibility is for some or all of a patient's problems

- if the relinquished responsibility is for some problems only, the original provider retains care responsibility for patient's all other problems

Referral and Transition of Care Data Requirements/Data Sets

Referral

Transition of Care

• MU2 appears to specify that the Summary Care Record is to be used for information exchanges to support Transition of Care

A summary of care record is specified in the MU2 Measure (2013 Nov) document to include the following elements:

Patient name.

Referring or transitioning provider's name and office contact information (EP only).

Procedures.

Encounter diagnosis

Immunizations.

Laboratory test results.

Vital signs (height, weight, blood pressure, BMI).

Smoking status.

Functional status, including activities of daily living, cognitive and disability status

Demographic information (preferred language, sex, race, ethnicity, date of birth).

Care plan field, including goals and instructions.

Care team including the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider.

Discharge instructions

Current problem list (Hospitals may also include historical problems at their discretion).

Current medication list, and

Current medication allergy list.

(Source: Eligible Hospital and Critical Access Hospital Meaningful Use Core Measures Measure 12 of 16 - 2013-Nov, p.2)

• The The Massachusetts Technology Collaborative has published a "Transfer of Care (CDA) Implementation Guide" to support Transition of Care.

This implementation guide specifies the following sections:

5.1 Advance Directives Section (entries optional)

5.2 Allergies Section (entries optional)

5.2.1 Allergies Section (entries required)

5.3 Assessment Section

5.4 Chief Complaint and Reason for Visit Section

5.5 Encounters Section (entries optional)

5.5.1 Encounters Section (entries required)

5.6 Family History Section

5.7 Functional Status Section

5.8 History of Past Illness Section

5.9 History of Present Illness Section

5.10 Hospital Discharge Diagnosis Section

5.11 Immunizations Section (entries optional)

5.11.1 Immunizations Section (entries required)

5.12 Medical Equipment Section

5.13 Medications Section (entries optional)

5.13.1 Medications Section (entries required)

5.14 Payers Section

5.15 Physical Exam Section

5.16 Plan of Care Section

5.17 Problem Section (entries optional)

5.17.1 Problem Section (entries required)

5.18 Procedures Section (entries optional)

5.18.1 Procedures Section (entries required)

5.19 Results Section (entries optional)

5.19.1 Results Section (entries required)

5.20 Social History Section

5.21 Vital Signs Section (entries optional)

5.21.1 Vital Signs Section (entries required)

(Source: Massachusetts Technology Collaborative - Transfer of Care Implementation Guide 2013-03)

Related Documents

Storyboards and Use Cases

Relevant References

FHIR Resources relevant to Referral project

• Link to FHIR Resources Proposals wiki:

http://wiki.hl7.org/index.php?title=Category:FHIR_Resource_Proposal

• Link to FHIR Clinical Resources wiki:

http://hl7.org/implement/standards/fhir/clinical.html

• This is the link to a blog on Referrals created by David Hay on Referral:

http://fhirblog.com/2014/03/31/referrals-orders-and-fhir/